Provider Demographics
NPI:1124387956
Name:FERNANDE, ROXANA C
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:C
Last Name:FERNANDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11821 TEALE ST
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7701
Mailing Address - Country:US
Mailing Address - Phone:310-418-4456
Mailing Address - Fax:310-390-8878
Practice Address - Street 1:11821 TEALE ST
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-7701
Practice Address - Country:US
Practice Address - Phone:310-418-4456
Practice Address - Fax:310-390-8878
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 5583225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist